Hospital work in psychiatry has a long, proud tradition. The severely mentally ill were housed in asylums in the historical past. In fact the origin of the word “bedlam” is derived from the pronunciation of Bethlehem and came to be synonymous with chaos. Bethlehem was the name of an insane asylum in London. Some aspects of current psychiatric hospital care still feel like bedlam.
A typical day for an inpatient psychiatrist involves rounding individually after a team meeting with social workers, nurses, and other members of the treatment team to determine events and observations during the previous 24 hours. The primary reasons for admission to inpatient services are imminent risk to self or others (suicide or homicide), psychotic disorders with inability to function, or severe anxiety or depression with inability to function. Geriatric units often deal with behavioral dyscontrol secondary to dementing illnesses or other neurologic disorders.
Practically speaking, the vast majority of admissions result from concerns related to the safety of the patient or others. For inpatient psychiatry the focus is acute stabilization and safety. This focus on stabilization often involves collaborating with outpatient members of the patient’s treatment team, including case managers and outside psychiatrists and therapists. Involving family in obtaining the patient’s collateral history is vital. The goal is to develop a treatment plan to address support, reasons for suicide, access to means for suicide, and treat underlying psychiatric syndromes.
Nonadherence to medication is another primary reason for admission. Patients with bipolar disorder, depression, and schizophrenia often stop taking their medications. Some of this is related to the underlying illness, while some is related to difficulties associated with medication side-effect profiles. Often, psychotic patients may have a fairly dramatic change in control of their symptoms after restarting their previous medications.
PSYCHIATRISTS IN HOSPITALS
Primary hospital work is not uncommon in the United States. A common arrangement is for a single psychiatrist or small group of psychiatrists to primarily manage an inpatient practice and see outpatients in the afternoon, depending on the size of the hospital.
Many psychiatrists lack interest in inpatient work, however. This lack of interest is related to the severity of symptoms, legal interface, call, and challenges with coordinating inpatient care with an outpatient practice.
The advantages of a dedicated psychiatric hospital practice are the same as for other hospitalists: The hospitalist develops both efficiencies and best practices based on seeing severe and complex problems repeatedly. They may also have knowledge of the community resources for the severely ill, which private outpatient psychiatrists may not be familiar with.
Psychiatric hospital work is always interesting and a great opportunity to work with severely ill patients who can be helped dramatically. The treatment is team-focused and offers the chance to work closely with social work, nursing, occupational therapy, psychology, and the community. It also allows for experience working with lawyers and the court system on a regular basis. Additionally, there’s often an opportunity to develop expert witness skills in some settings.
Academically, inpatient work is critical to resident and medical student education. It provides a chance for developing physicians to see and understand the realities and suffering associated with mental illness and their medical basis.
Psychiatric hospital medicine is emotionally intense work. Burnout is a major concern.
Many patients are not in the hospital voluntarily and don’t have insight into their illness. Nonadherence to treatment is common and the factor behind many admissions. Behaviorally, patients may be out of control from psychosis or severe personality disorders. Many have traumatic psychosocial histories and lack social supports. A number face legal charges. The intensity of practice is also due to the pressures of time, shortages of services for the mentally ill as outpatients, and pressures from both managed care and regulatory agencies.
EVOLUTION OF THE SPECIALTY
The state of hospital psychiatry has changed greatly in the past 40 or 50 years. The introduction of the antipsychotics solely for schizophrenia means we can now treat those previously thought untreatable. With the discovery and application of other treatments for mental illness, a movement developed to end the institutionalization of the mentally ill and integrate them back into the community. Other societal forces include the patient rights movement that has led to changes in the law and a needed focus on the rights of the mentally ill—both for minimums of treatment provided and protection against unnecessary hospitalization. State and federal budgetary and managed care pressures have also contributed to the remarkable changes in hospital psychiatry.
This combination of changes from medical, legal, societal, and fiscal forces has slashed the number of available inpatient beds and lengths of stays. In 1970 there were 413,066 state and county psychiatric inpatient beds in the United States.1 By 2000 that number had decreased to 59,403. There has been a moderate increase in private and community psychiatric beds in response. However, even considering this increase, the total number of beds in 1970 was
524,878 and the total in 2000 was 215,221. There have been continued reductions in beds since then nationally. Along with this decrease in psychiatric beds has come a dramatic shift in average length of stay as well. The general average length of stay in the United States is less than one week for psychiatric hospitalization.
The hope with decreasing the number of beds has been that a focus on community-based treatment and programs to support those with severe mental illness would be available to meet the needs of the severely mentally ill. Unfortunately, though the intent and goals were laudable, those programs have not developed as hoped. Current challenges for the seriously mentally ill include lack of parity for mental illness for insurance, continued pressure on private psychiatric beds to fill in the gaps of services not met by the community along with continued cuts in state and federal funding for inpatient psychiatric care.
This decrease in beds combined with decreased average length of stay and an increase in population has led to more and more pressure on the limited psychiatric beds available. It’s not uncommon now for patients to remain in the emergency department for 24 hours or longer waiting for a psychiatric bed. Along with these pressures has come decreased availability of inpatient substance abuse treatment, the ubiquitous comorbidity. Managed care review of inpatient stays on an almost daily basis, and the ever-increasing demands of documentation to meet regulatory requirements have also increased pressures on hospital psychiatry.
TYPES OF PSYCH HOSPITALIST PROGRAMS
As a result of the trends mentioned above, a variety of psychiatric hospitalist practice settings now exist. They include private and community psychiatric hospitals, academic center hospitals, state hospitals, Veterans Affairs and military hospitals, and—the most rapidly growing sector—correctional psychiatry in state and federal prison systems.
Correctional settings, such as jails and prisons, have been estimated by the Bureau of Justice Statistics to have a prevalence of inmates with mental illness between 7% and 16%.2 The rate of mental illness in inmates is approximately two to three times that of the general population for major mental illnesses such as schizophrenia, bipolar disorder, and major depressive disorder. The mentally ill in prison are more likely to be homeless, medically ill, and chemically dependent than the general population, as well.
Mentally ill inmates serve longer prison sentences on average than their mentally healthy peers. Mentally ill inmates are involved more commonly in disciplinary problems in prison also.
Overall, approximately 60% of mentally ill inmates receive some sort of mental health treatment while in custody. Two-thirds of inmates receiving treatment are in facilities that do not specialize in mental health treatment. Of state prisons, 155 specialize in mental health treatment—out of more than 1,500 facilities surveyed.3 Twelve facilities have mental health treatment as their primary function. Fewer than 2% of state inmates were housed in a mental health unit providing 24-hour care.
Psychiatric hospitalists in specialized treatment correctional settings have the opportunity to perform assessments and provide treatment to a patient population with a prevalence and severity of psychopathology that is not commonly seen in community psychiatric inpatient or outpatient practice today.
Inpatient psychiatry will continue to be important in the future. There are great challenges ahead but the need for dedicated hospital psychiatrists won’t go away and will probably increase. The pressures on the shrinking number of inpatient beds will continue to grow. The lack of outpatient services in general and intensive outpatient services available to transition patients to on discharge is frustrating. The continued de-emphasis on availability of substance abuse treatment continues to perplex. TH
Dr. Lineberry is medical director, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn. Dr. Shine is senior associate consultant, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn.
- Manderscheid RW, Atay JE, Hernandez-Cartagena MR, et al. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, U.S. Department of Health and Human Services. Mental Health, United States, 2002. Chapter 18. Highlights of organized mental health services in 2000 and major national and state trends. Available at www.mentalhealth.org/publications/allpubs/SMA04-3938/. Last accessed July 29, 2005.
- Bureau of Justice Statistics, Department of Justice. Mental health and treatment of inmates and probationers. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtip.pdf. Last accessed July 29, 2005.
- Bureau of Justice Statistics, Department of Justice. Mental health treatment in state prisons. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtsp00.pdf. Last accessed July 29, 2005.